A multi-level qualitative analysis of Telehomecare in Ontario: challenges and opportunities

Gemma Hunting, Nida Shahid, Yeva Sahakyan, Iris Fan, Crystal R Moneypenny, Aleksandra Stanimirovic, Taylor North, Yelena Petrosyan, Murray D Krahn, Valeria E Rac, Gemma Hunting, Nida Shahid, Yeva Sahakyan, Iris Fan, Crystal R Moneypenny, Aleksandra Stanimirovic, Taylor North, Yelena Petrosyan, Murray D Krahn, Valeria E Rac

Abstract

Background: Despite research demonstrating the potential effectiveness of Telehomecare for people with Chronic Obstructive Pulmonary Disease and Heart Failure, broad-scale comprehensive evaluations are lacking. This article discusses the qualitative component of a mixed-method program evaluation of Telehomecare in Ontario, Canada. The objective of the qualitative component was to explore the multi-level factors and processes which facilitate or impede the implementation and adoption of the program across three regions where it was first implemented.

Methods: The study employs a multi-level framework as a conceptual guide to explore the facilitators and barriers to Telehomecare implementation and adoption across five levels: technology, patients, providers, organizations, and structures. In-depth semi-structured interviews and ethnographic observations with program stakeholders, as well as a Telehomecare document review were used to elicit key themes. Study participants (n = 89) included patients and/or informal caregivers (n = 39), health care providers (n = 23), technicians (n = 2), administrators (n = 12), and decision makers (n = 13) across three different Local Health Integration Networks in Ontario.

Results: Key facilitators to Telehomecare implementation and adoption at each level of the multi-level framework included: user-friendliness of Telehomecare technology, patient motivation to participate in the program, support for Telehomecare providers, the integration of Telehomecare into broader health service provision, and comprehensive program evaluation. Key barriers included: access-related issues to using the technology, patient language (if not English or French), Telehomecare provider time limitations, gaps in health care provision for patients, and structural barriers to patient participation related to geography and social location.

Conclusions: Though Telehomecare has the potential to positively impact patient lives and strengthen models of health care provision, a number of key challenges remain. As such, further implementation and expansion of Telehomecare must involve continuous assessments of what is working and not working with all stakeholders. Increased dialogue, evaluation, and knowledge translation within and across regions to understand the contextual factors influencing Telehomecare implementation and adoption is required. This can inform decision-making that better reflects and addresses the needs of all program stakeholders.

Figures

Figure 1
Figure 1
A multi-level framework predicting implementation outcomes. Modified from Chaudoir et al. Implementation Science 2013, 8:22

References

    1. World Health Organization (WHO). Chronic Obstructive Pulmonary Disease (COPD). Factsheet Volume 315. 2015. . Accessed 15 April 2015.
    1. Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M, et al. The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J Am Coll Cardiol. 2014;63(12):1123–33. doi: 10.1016/j.jacc.2013.11.053.
    1. Heart and Stroke Foundation. Heart Failure. 2015. . Accessed 14 April 2015.
    1. Evans J, Chen Y, Camp PG, Bowie DM, McRae L. Health Reports. Canada: Statistics Canada; 2014. Estimating the prevalence of COPD in Canada: reported diagnosis versus measured airflow obstruction; pp. 3–11.
    1. Canadian Institute for Health Information (CIHI) All-cause readmission to acute care and return to the emergency department. Ottawa, Ont: Canadian Institute for Health Information (CIHI); 2012.
    1. Hawkins NM, Virani S, Ceconi C. Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services. Eur. Heart J. 2013;34(36):2795-2807.
    1. Alrajab S, Smith TR, Owens M, Areno JP, Caldito G. A home telemonitoring program reduced exacerbation and healthcare utilization rates in COPD patients with frequent exacerbations. Telemed J E Health. 2012;18(10):772–6. doi: 10.1089/tmj.2012.0005.
    1. Jia H, Chuang HC, Wu SS, Wang X, Chumbler NR. Long-term effect of home telehealth services on preventable hospitalization use. J Rehabil Res Dev. 2009;46(5):557–66. doi: 10.1682/JRRD.2008.09.0133.
    1. Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ. 2012;344 doi: 10.1136/bmj.e3874.
    1. Gellis ZD, Kenaley B, McGinty J, Bardelli E, Davitt J, Ten Have T. Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: a randomized controlled trial. Gerontologist. 2012;52(4):541–52. doi: 10.1093/geront/gnr134.
    1. Lamothe L, Fortin JP, Labbe F, Gagnon MP, Messikh D. Impacts of telehomecare on patients, providers, and organizations. Telemed J E Health. 2006;12(3):363–9. doi: 10.1089/tmj.2006.12.363.
    1. Radhakrishnan K, Jacelon C. Impact of telehealth on patient self-management of heart failure: a review of literature. J Cardiovasc Nurs. 2012;27(1):33–43. doi: 10.1097/JCN.0b013e318216a6e9.
    1. Sicotte C, Pare G, Morin S, Potvin J, Moreault MP. Effects of home telemonitoring to support improved care for chronic obstructive pulmonary diseases. Telemed J E Health. 2011;17(2):95–103. doi: 10.1089/tmj.2010.0142.
    1. Cruz J, Brooks D, Marques A. Home telemonitoring in COPD: A systematic review of methodologies and patients’ adherence. Int J Med Inform. 2014;83(4):249–63. doi: 10.1016/j.ijmedinf.2014.01.008.
    1. Thokala P, Baalbaki H, Brennan A, Pandor A, Stevens JW, Gomersall T, et al. Telemonitoring after discharge from hospital with heart failure: cost-effectiveness modelling of alternative service designs. BMJ Open. 2013;3(9) doi: 10.1136/bmjopen-2013-003250.
    1. Chrysanthaki T, Hendy J, Barlow J. Stimulating whole system redesign: Lessons from an organizational analysis of the Whole System Demonstrator programme. J Health Serv Res Policy. 2013;18(s1):47–55. doi: 10.1177/1355819612474249.
    1. Dinesen B, Nøhr C, Andersen SK, Sejersen H, Toft E. Under surveillance, yet looked after: Telehomecare as viewed by patients and their spouse/partners. Eur J Cardiovasc Nurs. 2008;7(3):239–46. doi: 10.1016/j.ejcnurse.2007.11.004.
    1. Gagnon MP, Duplantie J, Fortin JP, Lamothe L, Legare F, Labrecque M. Integrating scientific evidence to support telehomecare development in a remote region. Telemed J E Health. 2009;15(2):195–8. doi: 10.1089/tmj.2008.0070.
    1. Hendy J, Chrysanthaki T, Barlow J, Knapp M, Rogers A, Sanders C, et al. An organisational analysis of the implementation of telecare and telehealth: the Whole Systems Demonstrator. BMC Health Serv Res. 2012;12(1):403. doi: 10.1186/1472-6963-12-403.
    1. May CR, Finch TL, Cornford J, Exley C, Gately C, Kirk S, et al. Integrating telecare for chronic disease management in the community: what needs to be done? BMC Health Serv Res. 2011;11(1):131. doi: 10.1186/1472-6963-11-131.
    1. Sanders C, Rogers A, Bowen R, Bower P, Hirani S, Cartwright M, et al. Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study. BMC Health Serv Res. 2012;12(1):220. doi: 10.1186/1472-6963-12-220.
    1. Ontario Telemedicine Network (OTN). OTN best advice: the case for Telehomecare. 2014.. Accessed 21 March 2015.
    1. McLean S, Nurmatov U, Liu Joseph LY, Pagliari C. Car Jp, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011, Issue 7. Art. No.: CD007718. DOI:10.1002/14651858.CD007718.pub2.
    1. Sattoe JN, Bal MI, Roelofs PD, Bal R, Miedema HS, van Staa A. Self-management interventions for young people with chronic conditions: a systematic overview. Patient Educ Couns. 2015;98(6):704–715. doi: 10.1016/j.pec.2015.03.004.
    1. Glascock AP. A conflicted view of telehomecare after a 20 year journey. Volume 32. In: Assistive technology research series. Amsterdam: IOS Press; 2012.
    1. Hebert MA, Korabek B. Stakeholder readiness for telehomecare: implications for implementation. Telemed J E Health. 2004;10(1):85–92. doi: 10.1089/153056204773644625.
    1. Hendy J, Barlow J, Chrysanthaki T. Implementing remote care in the UK: an update of progress. Eurohealth. 2011;17(2):21.
    1. Weinhold I, Gastaldi L, Häckl D. Telemonitoring: criteria for a sustainable implementation. In: Sebastian Gurtner KS, editor. Challenges and opportunities in health care management. Switzerland: Springer International Publishing; 2015. p.307–318.
    1. Chaudoir SR, Dugan AG, Barr CH. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implement Sci. 2013;8(1):22. doi: 10.1186/1748-5908-8-22.
    1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and policy in mental health. 2011;38(2):65–76. doi: 10.1007/s10488-010-0319-7.
    1. Kuzel A. Sampling in qualitative inquiry. In: Crabtree BF, Miller WL, editors. Doing qualitative research. 2nd ed. Thousand Oaks, California: SAGE Publications; 1999. p. 33–45.
    1. Farmer T, Robinson K, Elliott SJ, Eyles J. Developing and implementing a triangulation protocol for qualitative health research. Qual Health Res. 2006;16(3):377–94. doi: 10.1177/1049732305285708.
    1. DiCicco-Bloom B, Crabtree BF. The qualitative research interview. Medical Education. 2006;40(4):314–21. doi: 10.1111/j.1365-2929.2006.02418.x.
    1. Bluff R. Grounded theory: the methodology. In: Holloway I, editor. Qualitative research in health care. London: Open University Press; 2005. pp. 147–67.
    1. Reeves S, Kuper A, Hodges BD. Qualitative research methodologies: ethnography. BMJ. 2008;337:a1020. doi: 10.1136/bmj.a1020.
    1. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Hawthorne, N.Y: Aldine de Gruyter; 1967.
    1. Strauss A, Corbin J. Basics of qualitative research. Newbury Park, CA: Sage; 1998.
    1. Hesse-Biber SN, Leavy P. The practice of qualitative research. 2 edn. Thousand Oaks, CA: Sage Publications, Inc; 2010.
    1. Eakin JM, Mykhalovskiy E. Reframing the evaluation of qualitative health research: reflections on a review of appraisal guidelines in the health sciences. J Eval Clin Pract. 2003;9(2):187–94. doi: 10.1046/j.1365-2753.2003.00392.x.
    1. Gearing RE. Bracketing in research: a typology. Qual Health Res. 2004;14(10):1429–52. doi: 10.1177/1049732304270394.
    1. Erzerberger C, Prein G. Triangulation. Validity and empirically based hypothesis construction. Qual Quant. 1997;31(2):141–54. doi: 10.1023/A:1004249313062.
    1. Yin R. Case study research: design and methods. Fourth edition. Los Angeles, Calif: Sage Publications, Inc; 2009.
    1. Ontario Telemedicine Network (OTN). Welcome to the OTN Telehomecare Centre. 2015. . Accessed 13 Feb 2015
    1. Rogers A, Kirk S, Gately C, May CR, Finch T. Established users and the making of telecare work in long term condition management: implications for health policy. Soc Sci Med. 2011;72(7):1077–84. doi: 10.1016/j.socscimed.2011.01.031.
    1. Liddy C, Dusseault JJ, Dahrouge S, Hogg W, Lemelin J, Humbert J. Telehomecare for patients with multiple chronic illnesses: pilot study. Can Fam Physician. 2008;54(1):58–65.
    1. Dinesen B, Gustafsson J, Nøhr C, Andersen SK, Sejersen H, Toft E. Implementation of the concept of home hospitalisation for heart patients by means of telehomecare technology: integration of clinical tasks. Int J Integr Care. 2007; 7(2):e17.
    1. Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario’s family health team model: a patient-centered medical home. Ann Fam Med. 2011;9(2):165–71. doi: 10.1370/afm.1228.
    1. Tracy CS, Bell SH, Nickell LA, Charles J, Upshur RE. The IMPACT clinic innovative model of interprofessional primary care for elderly patients with complex health care needs. Can Fam Physician. 2013;59(3):e148–55.
    1. Moore A, Patterson C, White J, House ST, Riva JJ, Nair K, et al. Interprofessional and integrated care of the elderly in a family health team. Can Fam Physician. 2012;58(8):e436–41.
    1. Prasad S, Dunn W, Hillier LM, McAiney CA, Warren R, Rutherford P. Rural geriatric glue: a nurse practitioner–led model of care for enhancing primary care for frail older adults within an ecosystem approach. J Am Geriatr Soc. 2014;62(9):1772–80. doi: 10.1111/jgs.12982.
    1. Health Quality Ontario. Experiencing integrated care: Ontarians’ views of health care coordination and communication. 2015. . Accessed 20 April 2015.
    1. Wodchis WP, Williams AP, Mery G. Integrating care for persons with chronic health and social needs. White paper working draft for Creating Strategic Change in Canadian Healthcare Conference. Toronto, ON: Health System Performance Research Network; 2014.
    1. Ontario Telemedicine Network (OTN). OTN update. 2013. . Accessed 5 March 2015.
    1. Brassolotto J, Raphael D, Baldeo N. Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry. Crit Public Health. 2014;24(3):321–36. doi: 10.1080/09581596.2013.820256.
    1. Kessler R, Glasgow RE. A proposal to speed translation of healthcare research into practice. Am J Prev Med. 2011;40(6):637–44. doi: 10.1016/j.amepre.2011.02.023.
    1. Hunting G, Shahid N, Sahakyan Y, Fan I, Badr S, Moneypenny C, et al. Program evaluation of Telehomecare for patients with Heart Failure or Chronic Obstructive Pulmonary Disease: Telecare (TLC) Study. Qualitative Comparative Case Study Report. Toronto, ON: THETA Collaborative in conjunction with Ontario Ministry of Health and Long-Term Care (MOHLTC); 2015.

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